Special Investigation Unit Nurse Consultant - Remote

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time remote position with less than 5% required travel. Requirement to reside in the contiguous U.S. Hours for this position are 8am-5pm in time zone of residence.

RN and certified coder Responsible for the review and evaluation of clinical information and documentation related to SIU flagged providers. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for Investigators customer service and claims processing areas. Requires an RN with unrestricted active license. Must be a Certified Coder. Must have experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews.